Prevalence of Seeking Traditional Healers in the Treatment of Hemorrhoids and Its Complications among Patients with Hemorrhoidal Visiting the Surgical Outpatient Clinic at a Somali Sudanese Sepcialized Hospital in Mogadisho, Somali ()
1. Introduction
Hemorrhoids, also known as piles, are swollen veins located in the anus and lower rectum. This condition is primarily caused by increased pressure in the veins, often due to straining during bowel movements or other activities that put strain on the area. As pressure increases, blood pools in the veins increase, which causes them to swell, thus stretching the surrounding tissue [1].
The most common and severe effects of haemorrhoids are perianal throm-bosis, and incarcerated prolapsed internal haemorrhoids with subsequent thrombosis [2].
Various studies revealed that constipation, diarrhoea, insufficient dietary fibre, chronic straining during defaecation, abdominal obesity, depression, pregnancy hyper-tension, smoking as well as advancement in age and sedentary lifestyle are common risk factors for the development of haemorrhoids. Globally, very few studies have been conducted to study the prevalence of haemorrhoids. For instance, in Africa, the prevalence of the disease is 18% in Egypt and 13.1% in Ethiopia [3].
Hemorrhoidal disease is one of the most common anorectal conditions encountered in daily practice in India. It has been projected that about 50% of the population will have hemorrhoids at some point in their life [4].
Hemorrhoids are dilated veins of the superior hemorrhoidal veins, in relation to the anal canal [5]. They represent abnormal enlargement of the anal cushions [6]. Clinically characterized by bleeding from the rectum, mucous discharge, perianal itching or pruritus, perianal pain, prolapse of the hemorrhoidal cushions, or protruding mass, the exact prevalence of symptomatic hemorrhoids is difficult to measure [7].
In the United States, it is the fourth leading outpatient gastrointestinal diagnosis, accounting for 3.3 million ambulatory care visits. Despite its prevalence and low morbidity, hemorrhoid disease has a high impact on the quality of life [8].
2. Methods and Materials
2.1. Study Design, Setting and Study Period
Institutional based cross sectional study design was applied to assess prevalence of seeking traditional healers in the treatment of hemorrhoids and its complications among patients with hemorrhoid visiting the surgical outpatient clinic at a Somali Sudanese in Mogadishu, Somalia from July to January 2023. This hospital offers the most comprehensive services for patients with hemorrhoids.
2.2. Study Population and Eligibility Criteria
The study population included all patients diagnosed with hemorrhoid disease who sought medical care at the surgical department during the specified study period. All patients diagnosed with hemorrhoid disease who consented to participate in the study were included. Exclusion criteria included patients with mental illness or those who were critically ill were excluded.
2.3. Sample Size Determination and Sample Technique
The sample size was calculated using the single population proportion formula, with a 95% confidence interval and a margin of error of 0.05. A prior study conducted in Ethiopia, which estimated the prevalence of hemorrhoids at 16%, was used to guide this calculation. Based on these parameters, the required sample size was determined to be 206 participants. A systematic random sampling technique was employed to select participants, applying a skipping interval of three to ensure a representative sample.
2.4. Data Processing and Analysis
A structured questionnaire was employed to gather data from the study population. The questionnaire consisted of three main sections: sociodemographic characteristics (e.g., age, gender), post-traditional management complications (such as bleeding, pain, infections, edema, and fistula), and the status of traditional healers. Data collection was carried out by five trained B.Sc. nurses who were currently working at the surgical outpatient department (OPD), using the Koba toolbox.
To ensure data quality, a two-day training session was provided for the data collectors, equipping them with the necessary skills for accurate data collection. Prior to the main data collection, a pretest was conducted on 10% of the sample size at Somali Sudanese Hospital to assess the clarity, approachability, and feasibility of the questionnaire. Based on the results of the pretest, necessary corrections and modifications were made to the questionnaire to enhance its effectiveness and reliability.
2.5. Data Analysis and Management
Once data collection was complete, each questionnaire was thoroughly reviewed to ensure all responses were recorded. The data were then coded and entered using EPI DATA version 3.1, before being exported to STATA 14 for analysis. Data cleaning involved identifying and correcting any missing values or inconsistencies. Descriptive statistics, including frequencies and percentages, were calculated to characterize the study population across various variables. A Chi-square test was conducted to assess the relationships between variables, with a 95% confidence interval and a p-value of less than 0.05 considered to indicate a statistically significant association with the outcome variable.
2.6. Ethical Considerations
Ethical approval was obtained, and informed consent was collected from participants.
3. Results
3.1. Demographics and Symptoms of the Study Population
1) Gender:
Similar gender distribution among those seeking and not seeking traditional healing (p = 0.765, not significant).
67.8% of males sought traditional healing versus 65.5% of males who did not.
2) Age:
3) Symptoms:
Swelling was the most common symptom in both groups (~91%, p = 0.85, not significant).
Other symptoms like bleeding (p = 0.147), itching (p = 0.094), and discharge (p = 0.074) showed no significant differences between the groups.
3.2. Post-Traditional Healing Complications
1) Significant Complications (p < 0.001):
2) Non-Significant Complication:
3.3. Interventions by Traditional Healers
1) Common Interventions:
Injections: 64.4% in the traditional healing group vs. 4.5% in the non-traditional group (p < 0.001).
Creams: 18.9% vs. 2.7% (p < 0.001).
Oral tablets: 17.8% vs. 0% (p < 0.001).
Oral liquids: 20% vs. 3.6% (p < 0.001).
2) Implications:
3.4. Key Takeaways
Age and certain post-treatment complications like bleeding, pain, infection, and edema are significantly associated with traditional healing practices.
Traditional healing methods involve specific interventions (e.g., injections and oral liquids) that differ from conventional medical approaches.
The data suggest a need for targeted education and intervention to address complications and ensure safer practices in traditional healing.
Table 1. Gender, age and symptoms of hemorrhoid among the study population.
Variable |
Seeking Traditional Healing |
Chi-Square Test |
p-value |
Yes |
No |
Gender |
Male |
61 (67.8) |
72 (65.5) |
0.12 |
0.765 |
Female |
29 (32.2) |
38 (34.5) |
Age |
<30 |
9 (10) |
31 (28.2) |
16 |
<0.001 |
30 - 59 |
48 (53.3) |
61 (55.5) |
60+ |
33 (36.7) |
18 (16.4) |
Swelling |
Yes |
82 (91.1) |
101 (91.8) |
0.032 |
0.85 |
No |
8 (8.9) |
9 (8.2) |
Bleeding |
Yes |
51 (56.7) |
51 (46.4) |
2.1 |
0.147 |
No |
39 (43.3) |
59 (53.6) |
Itching |
Yes |
45 (50) |
42 (38.2) |
2.81 |
0.094 |
No |
45 (50) |
68 (61.8) |
Discharge |
Yes |
25 (27.8) |
19 (17.3) |
3.2 |
0.074 |
No |
65 (72.2) |
91 (82.7) |
Table 1 provides an analysis of the demographic characteristics and symptomatology of the study population, specifically comparing individuals seeking traditional healing to those not seeking traditional healing. The gender distribution indicates that 61 males (67.8%) sought traditional healing compared to 72 males (65.5%) who did not, while 29 females (32.2%) sought traditional healing compared to 38 females (34.5%) who did not. The Chi-Square test value for gender is 0.12, with a p-value of 0.765, indicating no statistically significant difference in gender distribution between the two groups.
Age distribution reveals a notable difference: only 9 individuals (10%) under 30 years sought traditional healing compared to 31 individuals (28.2%) who did not. For the 30 - 59 age group, 48 individuals (53.3%) sought traditional healing, compared to 61 individuals (55.5%) who did not. In the 60+ age group, 33 individuals (36.7%) sought traditional healing compared to 18 individuals (16.4%) who did not. The Chi-Square test value for age is 16, with a p-value of less than 0.001, indicating a significant difference in age distribution between those seeking and not seeking traditional healing.
Regarding symptoms, 82 individuals (91.1%) with swelling sought traditional healing, compared to 101 individuals (91.8%) who did not, with a Chi-Square test value of 0.032 and a p-value of 0.85, indicating no significant difference. For bleeding, 51 individuals (56.7%) sought traditional healing compared to 51 individuals (46.4%) who did not, with a Chi-Square test value of 2.1 and a p-value of 0.147, also showing no significant difference. In terms of itching, 45 individuals (50%) sought traditional healing compared to 42 individuals (38.2%) who did not, with a Chi-Square test value of 2.81 and a p-value of 0.094, indicating a marginally non-significant difference. Lastly, for discharge, 25 individuals (27.8%) sought traditional healing compared to 19 individuals (17.3%) who did not, with a Chi-Square test value of 3.2 and a p-value of 0.074, showing a near-significant trend. These results suggest that while age is a significant factor, most symptom variables do not show a statistically significant difference in relation to seeking traditional healing.
Table 2. Post traditional management complications among the study population.
Variable |
Seeking Traditional Healing |
Chi-Square Test |
p-value |
Yes |
No |
Bleeding |
Yes |
24 (26.7) |
5 (4.5) |
19.5 |
<0.001 |
No |
66 (73.3) |
105 (95.5) |
Pain |
Yes |
48 (53.3) |
3 (2.7) |
66.7 |
<0.001 |
No |
42 (46.7) |
107 (97.3) |
Infection |
Yes |
23 (25.6) |
5 (4.5) |
18.1 |
<0.001 |
No |
67 (74.4) |
105 (95.5) |
Edema |
Yes |
30 (3.3) |
5 (4.5) |
28.4 |
<0.001 |
No |
60 (66.7) |
105 (95.5) |
Fistula |
Yes |
3 (3.3) |
2 (1.8) |
0.47 |
0.67 |
No |
87 (96.7) |
108 (98.2) |
Table 2 provides an in-depth comparison of post-traditional management complications among individuals who sought traditional healing versus those who did not. The variables examined include bleeding, pain, infection, edema, and fistula. For bleeding, 24 individuals (26.7%) who sought traditional healing reported this complication, compared to only 5 individuals (4.5%) who did not seek traditional healing. The Chi-Square test value for bleeding is 19.5 with a p-value of less than 0.001, indicating a highly significant difference, suggesting that those seeking traditional healing are more likely to experience bleeding.
Pain was reported by 48 individuals (53.3%) in the traditional healing group compared to only 3 individuals (2.7%) in the non-traditional group. The Chi-Square test value for pain is 66.7 with a p-value of less than 0.001, highlighting a significant difference. This indicates a much higher incidence of pain among those who sought traditional healing. Similarly, infection was noted in 23 individuals (25.6%) who sought traditional healing, compared to 5 individuals (4.5%) who did not, with a Chi-Square test value of 18.1 and a p-value of less than 0.001, demonstrating a significant difference.
Edema was another complication observed significantly more in the traditional healing group, with 30 individuals (33.3%) experiencing it compared to 5 individuals (4.5%) in the non-traditional group. The Chi-Square test value for edema is 28.4 with a p-value of less than 0.001, indicating a highly significant difference. In contrast, the occurrence of fistula was not significantly different between the groups, with 3 individuals (3.3%) in the traditional healing group and 2 individuals (1.8%) in the non-traditional group. The Chi-Square test value for fistula is 0.47 with a p-value of 0.67, indicating no significant difference.
In summary, the table clearly indicates that individuals seeking traditional healing are significantly more likely to experience complications such as bleeding, pain, infection, and edema. These findings suggest that traditional healing practices may be associated with a higher risk of certain post-treatment complications, underscoring the need for careful consideration and potential intervention in such practices.
Table 3. Traditional healers intervention provided for the study population.
Variable |
Seeking Traditional Healing |
Chi-Square Test |
p-value |
Yes |
No |
Injection |
Yes |
58 (64.4) |
5 (4.5) |
82.3 |
<0.001 |
No |
32 (35.6) |
105 (95.5) |
Creams |
Yes |
17 (18.9) |
3 (2.7) |
14.4 |
<0.001 |
No |
73 (81.1) |
107 (97.3) |
Oral tablets |
Yes |
16 (17.8) |
0 (0.0% |
21.3 |
<0.001 |
No |
74 (82.2%) |
110 (100%) |
Oral liquids |
Yes |
18 (20%) |
4 (3.6%) |
13.5 |
<0.001 |
No |
72 (80%) |
106 (96.4%) |
According to Table 3, a significant difference was found in the administration of injections (χ2 = 82.3, p < 0.001). Specifically, 58 individuals (64.4%) who sought traditional healing received injections, compared to only 5 individuals (4.5%) who did not. This indicates a much higher likelihood of receiving injections among those seeking traditional healing.
The use of creams also showed a significant difference (χ2 = 14.4, p < 0.001). Seventeen individuals (18.9%) who sought traditional healing received creams, while only 3 individuals (2.7%) who did not seek traditional healing received creams. This suggests a higher likelihood of cream use among those seeking traditional healing.
The administration of oral tablets revealed a significant difference (χ2 = 21.3, p < 0.001). Sixteen individuals (17.8%) who sought traditional healing received oral tablets, whereas no individuals who did not seek traditional healing received them. This indicates that oral tablets are more commonly administered by traditional healers.
The use of oral liquids was significantly higher among those seeking traditional healing (χ2 = 13.5, p < 0.001). Eighteen individuals (20%) who sought traditional healing received oral liquids, compared to 4 individuals (3.6%) who did not. This highlights the prevalence of oral liquid administration among traditional healers.
Overall, the data indicate that individuals who seek traditional healing are significantly more likely to receive various interventions, including injections, creams, oral tablets, oral liquids, and enemas, compared to those who do not seek traditional healing. These findings highlight substantial differences in treatment practices between traditional healers and other healthcare providers, emphasizing the unique approaches taken by traditional healers in managing their patients' health.
4. Discussion
Hemorrhoids are one of the most common anorectal problems, characterized by symptomatic swelling and the distal displacement of natural anal cushions. This condition has been documented since ancient times, with reports dating back to the dawn of recorded human history. Over half of men and women over the age of 50 may experience hemorrhoid symptoms at some point in their lives, making it a prevalent health issue among adults.
The main aim of pile management is to treat the symptoms and relief the pain and swelling rather than improving the appearance of the anal canal. The relationship between constipation and piles has been recognized for centuries, and dietary correction to prevent constipation and straining is widely recommended. In one study high fiber diet has been found to be better than placebo in reducing symptoms. In another study, some herbal remedy, there has been a significant improvement in the fiber treated group with first and second degree piles [9].
For hemorrhoid management, a strong preference for herbal treatments was reported, which was confirmed by both conventional medical practitioners and herbal vendors. However, there was a disagreement between the two groups regarding the impact of the condition. While medical practitioners focused on clinical symptoms, herbal vendors claimed there is a connection between hemorrhoids and sexual strength [10].
Depending on the severity and scope of the symptoms, haemorrhoids can be treated with life style management, medication, and surgical procedures. To reduce symptoms, stop their progression to more severe states, and avoid complications, conservative treatment approaches are needed. When non-operative methods have failed or complications have happened, surgery is indicated. Hemorrhoids can be managed using topical treatments like creams, lotions, and suppositories that include a variety of substances (local anaesthetics, corticosteroids, antibiotics, and anti-inflammatory medications). Although these medications aid in symptom improvement, there is a lack of compelling data to support their actual efficacy. Currently, herbal medications are dominating other options for treating a variety of ailments. For the treatment of their illnesses, about 90% of Ethiopians rely on traditional medicine, primarily herbal remedies. Hemorrhoids were listed as the fourth most often treated illness in Addis Abeba, Ethiopia, by traditional healers.
Previous studies have identified various treatments and procedures for hemorrhoids, but only a small number of respondents are familiar with options beyond conventional medical treatments, such as hemorrhoidectomy, or traditional remedies like herbal drinks and powders.
Previous studies on modern treatments for hemorrhoid have identified the therapies available to hemorrhoidal patients [11]. In addition, all of the herbal vendors stated that there is a special regimen that patients with internal hemorrhoids can apply to retract after defecation. This suggests that many of the respondents do not make the necessary enquiries about the other available therapies and procedures [12]. It is likely that the respondents have not received adequate information about hemorrhoid management, as the association test reveals a significant link between the fear of undergoing hemorrhoidectomy and the increased reliance on Jedijedi herbal treatments among police officers [11].
5. Conclusions
Seeking traditional healers for the treatment of hemorrhoids is very common in the Somali community. Herbal and traditional practitioners use various procedures for treating hemorrhoids, often without adequate knowledge or awareness of the potential risks and complications associated with these treatments.
There are misconceptions about hemorrhoids, herbal vendors, and their customers in the Ibadan metropolis. The misconceptions about hemorrhoids are evident in its associated causes, symptoms, and perceived effects, which are embedded in the sociocultural explanation of hemorrhoids. A low level of awareness necessitated the kind of diagnosis and management of hemorrhoids among the herbal vendors and their customers.
Authors’ Contributions
Dr. Abdihakim Elmi contributed to conception of the idea of the case report and first draft preparation collection of the data, discussion and references, and operating the case and follow-up till full recovery. Mr. Mohamed contributed to literature review, data collection and analysis and draft preparation.
Funding Source
No funding was needed for this case report, except for the amount required if published.
Clinical Trail Number
Not applicable.
Acknowledgements
To all surgery staff of Surgery Department who participated in data collection, data processing and patient management.
Ethical Statement
The patient provided informed written consent to publish this case study and accompanying photographs.
Conflicts of Interest
The authors declare no conflicts of interest.